The objective of this study is to determine the most effective surgical procedure for correcting velopharyngeal insufficiency (VPI). Toward this end, the two most commonly performed procedures, sphincter pharyngoplasty and pharyngeal flap, will be prospectively compared in terms of perceptual speech results, airway physiology, complications (including obstructive sleep apnea), facial growth, and financial costs. Subjects with repaired cleft palate and residual VPI, identified by perceptual speech evaluation and confirmed by video nasopharyngoscopy, will be prospectively randomized between sphincter pharyngoplasty and pharyngeal flap for surgical management. All subjects will be between the ages of three and nine years at the time of surgery, and standardized surgical techniques will be used at four participating centers. Subjects will be evaluated preoperatively, perioperatively, and postoperatively for several indicators of outcome, including perceptual speech evaluation, video nasopharyngoscopy, airway physiology, lateral cephalometric radiographs (resting and phonating), and polysomnographic sleep studies. The estimated number of subjects will be 292, enrolled during a four year period. Minimum follow-up will be one year, necessitating a total project period of five years.